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Apr 18 03 06:44p Fr--zen Hill 5596 <br />1614 67 p. <br />SWRCB, January 2002 Page 1 of 7 <br />H&M Escalon ,�J� <br />Secondary Containment Testing Report Form A z 1- <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested. The com letedform, -written test procedures, and ��� <br />�- <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agen X, <br />1. FACILITY INFORMATION --- <br />Facility <br />_Facility Name: H -M KWIK BOYETT I Date of Testing: 3-19-03 <br />Facility Address: 2501 JACKSON RD. ESCALON WO# 030301 Time: <br />Facility Contact: <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (ifpresent u <br />testing): <br />Phone: <br />r1f � T7A'1�T <br />Company Name: <br />Franzen -Hill Corp 1100 North J Street Tulare, CA 93?`l <br />Technician Conducting Test: FELIX MENDS -- <br />Credentials: x CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: <br />A,B,C-6I/D40 HAZ License Number: 304147 n� <br />Manufacturer Training <br />Manufacturer <br />_ <br />Component(s) Date Training ]Expires <br />Environ <br />Pipi!!g and Testing 10/03 <br />Total Containment <br />Piping and Testing_ 10/03 <br />Incon <br />Testing --- <br />Cadwell <br />Testing <br />^. c V M ffw,r ♦ Inv ,n V rrT. CST 1D'V4QYTT .TC <br />Not Repairs Not <br />Component Pass Fad Tested Made Component Pass Fait Tested <br />--- <br />Repairs <br />Made <br />— <br />UDC 3-4 X —. <br />-- <br />If hydrostatic testing was performed, describe what was done with the water after completion o"test3: <br />AT TMPPn S rTAI R OF CLEAN WATER BACK ON TO TRUCK <br />CERTIFICATION OF TEC19NICM-4 RESPONSIBLE FOR CONDUCTING, TRISTESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full comp{lance with legal requirements <br />Technician's S bQnature: FELIX MENDES Date: -3-19-03 <br />